Provider Demographics
NPI:1861547648
Name:HAGEDORN, DEBORAH M (LPN)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:M
Last Name:HAGEDORN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 E SHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:TIMBERLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44095-1903
Mailing Address - Country:US
Mailing Address - Phone:440-953-0395
Mailing Address - Fax:
Practice Address - Street 1:58 E SHORE BLVD
Practice Address - Street 2:
Practice Address - City:TIMBERLAKE
Practice Address - State:OH
Practice Address - Zip Code:44095-1903
Practice Address - Country:US
Practice Address - Phone:440-953-0395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN. 116989 MEDS IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2593671Medicaid